Research & Practice for Persons with Severe Disabilities
2004, Vol. 29, No. 2, 122–134
copyright 2004 by
TASH
A Systematic Desensitization Paradigm to
Treat Hypersensitivity to Auditory Stimuli
in Children with Autism in
Family Contexts
Robert L. Koegel, Daniel Openden, and Lynn Kern Koegel
University of California, Santa Barbara
Many children with autism display reactions to auditory stimuli that seem as if the stimuli were painful or
otherwise extremely aversive. This article describes,
within the contexts of three experimental designs, how
procedures of systematic desensitization can be used to
treat hypersensitivity to auditory stimuli in three young
children with autism. Stimuli included the sounds from a
vacuum cleaner, blender, hand-mixer, toilet flushing,
and specific animal sounds from musical toys. A changing criterion design was used and data were collected on
(a) the number of hierarchical steps completed as comfortable with the stimulus per week and (b) the mean
level of anxiety per probe. A clinical replication was
implemented using a replication of the desensitization
procedures for three children. In addition, a systematic
replication across three different stimuli is presented for
one child in a multiple baseline. The data show that the
children’s responses could be modified to the point
where they were comfortable with these noises. Furthermore, this level of comfort was maintained at follow-up.
The discussion suggests that the extreme reactions to auditory stimuli many children with autism exhibit may be
decreased with procedures that have been shown to be
effective with reducing phobias, and the possibility that
the reactions may be symptomatic of a phobia rather
than actual pain.
DESCRIPTORS: desensitization, autism, hypersensitivity, auditory stimuli, families
Many children with autism are described in the literature as having auditory abnormalities, including reports of hypersensitive hearing (Grandin & Scariano,
1986; Hayes & Gordon, 1977; Ney, 1979; Rimland,
1964; Rimland & Edelson, 1995). Since 1964, the Autism Research Institute has collected data from over
17,000 families of children with autism. Data reveal that
approximately 40% of parents of children with autism
reported that their child exhibited some symptoms of
sound sensitivity (Rimland & Edelson, 1995). Among
other hearing irregularities, children with autism have
been reported to frequently display an intense aversion
to auditory stimuli, which has led to the speculation that
they may even experience hyperacusis, a condition in
which exposure to particular sounds frequently causes
pain. The reaction can be so severe that an individual’s
ability to function is impaired and behaviors that are
disruptive, aggressive, self-injurious, or otherwise inappropriate are often displayed (Berkell, Malgeri, &
Streit, 1996; Brown, 1999). Exacerbating the problem is
that many children with autism are reported as being
most sensitive to common everyday environmental
sounds (Vicker, 1993).
Unfortunately, many interventions designed to address sensory impairments in children with autism have
not been well validated (Dawson & Watling, 2000;
Goldstein, 2000). The literature has further indicated
that it has been difficult to demonstrate objective and
reliable changes in auditory sensitivity (Gravel, 1994;
Rimland & Edelson, 1995; Tharpe, 1999). Thus, wellcontrolled, reliable studies are needed to develop effective interventions to address auditory sensitivity in
children with autism (Dawson & Watling, 2000; Goldstein, 2000).
The literature has also suggested that many children
with autism display phobias (Howlin et al., 1973; Jackson & King, 1982; Love, Matson, & West, 1990; Luiselli,
1978), many of which may be related to the difficulties
The authors thank the families who participated in this research. We also express our gratitude to Bill Frea and to the
students, Deanna Gerner and Lisa Howe, who assisted with
the data collection and reliability measures. Finally, we greatly
appreciate the feedback provided by Dr. George Singer and
Dr. Mike Gerber for their extensive feedback on earlier drafts
of this study.
Portions of the research reported in this study were supported by Research Grant MH28210 from the National Institute of Mental Health and by US Department of Education
Grant #5830-257-LO-B.
Address all correspondence and requests for reprints to
Robert L. Koegel, Counseling/Clinical/School Psychology Program, Graduate School of Education, University of California,
Santa Barbara, CA 93106-9490. E-mail: koegel@education.
ucsb.edu
122
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Using a Systematic Desensitization Paradigm
they have with auditory stimuli (Hemsley, 1978). In
other words, the child’s extreme aversion to these
stimuli may relate to an irrational fear of the stimulus
rather than to pain associated with the stimulus. Systematic desensitization is a procedure typically used to
treat phobias and is a common counterconditioning
procedure used with children (Center, 1989). Some researchers have demonstrated that systematic desensitization can be used to reduce fears for children with
autism during common experiences, such as a dental
examination (Luscre & Center, 1996).
The purpose of this study was to assess the effects of
a systematic desensitization intervention program on
the apparent hypersensitivity of children with autism to
common environmental auditory stimuli. Specifically,
this research was designed to evaluate whether these
children’s intolerant reaction to common everyday
sounds (vacuum cleaner, blender, hand-mixer, toilet
flushing, toys) could be modified using procedures of
desensitization to the point where the child would seem
comfortable with these stimuli.
Method
Participants
Three children, two boys and a girl, diagnosed with
autism were selected to participate in this study based
on their apparently severe hypersensitivity to auditory
stimuli. All children were diagnosed with autism by
their pediatrician and/or a California state agency specializing in developmental disabilities according to criteria listed in the Diagnostic and Statistical Manual of
Mental Disorders—Fourth Edition (American Psychiatric Association, 1994). The children were subsequently
referred to the University of California Santa Barbara
Autism Research and Training Center for intervention.
All demonstrated qualitative impairments in communication and social development, and all demonstrated a
restricted repertoire of interests.
Child 1, Lori, an Hispanic-American girl, was 3 years
and 7 months of age at the start of the study. Recent
standardized testing showed the following. On the
Vineland Adaptive Behavior Scales, Lori scored an age
equivalent of 1 year 4 months on the Communication
Domain, 1 year 9 months on the Daily Living Skills
Domain, 7 months on the Socialization Domain, and 2
years 9 months on the Motor Skills Domain, with an
Adaptive Behavior Composite of 1 year 7 months. Lori
attended a full inclusion preschool on the University of
California campus. On her first day of school, Lori’s
teachers noted that they were unable to take her to the
bathroom as she refused to enter the bathroom and
covered her ears every time the toilet flushed. Consequently, she had daily toileting accidents at school. Observations at home indicated that she did not react to
the toilet flushing at home, which was much quieter.
Preintervention probes confirmed that Lori began put-
123
ting her hands over her ears in the school hallway as the
children walked toward the bathroom, about 40 feet
away. In addition, she covered her ears and refused to
enter the bathroom, even when other children were not
present.
Child 2, Jamie, a Caucasian boy, was 2 years and 6
months of age at the start of the study. Recent standardized testing showed the following. On the Vineland
Adaptive Behavior Scales, Jamie scored an age equivalent of 1 year 7 months on the Communication Domain,
1 year 6 months on the Daily Living Skills Domain, 1
year 6 months on the Socialization Domain, and 3 years
8 months on the Motor Skills Domain, with an Adaptive Behavior Composite of 2 years 1 month. Prior to
the start of services Jamie’s mother reported that he
could not play with many toys because of his intolerance to certain sounds. Specifically, she reported that
he avoided all toys with animal sounds, and when one
was turned on he placed his hands over his ears,
screamed, cried, and ran away from the toy. Jamie’s
mother reported that he had been sensitive to sounds
all of his life, but at around 2 years of age, he began
displaying extreme aversive reactions to the toys. She
expressed concern that his play was extremely limited
as a result of this behavior. In addition, Jamie became
upset at the sight of toys that were associated with animal sounds, and consequently his mother constantly
avoided environments where similar toys were available, such as toy stores and friends’ homes. In addition,
Jamie’s mother was concerned that he may display
these extreme behaviors in a preschool setting, where
these types of toys are common. During preintervention probes collected when in the toy room at the University of California Autism Center, Jamie began to cry
at the sight of toys that made animal sounds and repeatedly requested that the toy be put away (i.e., “no,
no, no” or “all done”). If the noise was turned on, Jamie
engaged in more severe disruptive behaviors, including
covering his ears, screaming, crying, and attempting to
run out of the room. Prior to intervention, observations
were also made at the family’s home. Jamie’s mother
reported that she had put away all of the toys with
animal noises as a result of Jamie’s severe reaction to
the toys and was unwilling to take the toys out for a
baseline probe.
Child 3, Jeff, was 2 years and 7 months of age at the
start of the study. Jeff was a Eurasian boy who lived
with both parents and a younger brother. Recent standardized testing showed the following. On the Vineland
Adaptive Behavior Scales, Jeff scored an age equivalent of 1 year 5 months on the Communication Domain,
1 year 5 months on the Daily Living Skills Domain, 9
months on the Socialization Domain, and 2 years 9
months on the Motor Skills Domain, with an Adaptive
Behavior Composite of 1 year 5 months. Prior to the
start of services, Jeff’s mother reported that he appeared to be oversensitive to auditory stimuli, reacting
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Koegel et al.
in a way that suggested such stimuli were intolerable for
him. She began noticing his aversive reaction to the
sound of vacuum cleaners, blenders, and hand-mixers
when Jeff was about 18 months old and reported that
his reaction had worsened over time. Consequently,
Jeff’s apparent hypersensitivity had made a drastic impact on the quality of life for his family. For instance,
they often avoided vacuuming their home altogether or
began vacuuming only when Jeff was asleep or not in
the house. Similarly, they began avoiding other household appliances, particularly the blender and the handmixer, that appeared to be painful for Jeff. Finally, they
stopped going to Blenders, a family favorite smoothie
and juice bar. Jeff’s mother adamantly expressed the
family’s growing concern over his inability to coexist
with such stimuli and the inconvenience it caused their
family. Preintervention probes were performed in the
community and at the family’s home prior to the start
of intervention. At the mere mention and sight of both
the vacuum cleaner and the hand-mixer, Jeff engaged
in such behaviors as running away, crying, screaming,
forcefully placing his hands over his ears, and grinding
his teeth. When either stimulus was turned on, these
behaviors greatly increased and intensified. Similarly, a
preintervention probe taken at Blenders (smoothie and
juice bar) was terminated when Jeff began engaging in
the same behaviors in the surrounding shopping center
and was unable to enter the store.
Setting
Lori’s sessions were all implemented in her full inclusion preschool setting. The students’ bathroom was
located down the hall from the classroom (about 35
yards). The bathroom had two toilets and two sinks.
This was her only setting, because the problem was not
observed at any other time. During all of Lori’s sessions, a clinician from our center was present while
Lori’s teacher took her to the bathroom.
Intervention sessions for Jamie were all implemented
in a small clinic room located on the University campus.
The clinic room contained a large number of children’s
toys and a small table with chairs. Jamie’s mother and
a clinician from our center were present during all sessions. In addition, postintervention probes were collected at Jamie’s home during follow-up to assess for
generalization to a new setting with different toys that
also make animal sounds.
For Jeff, sessions for the vacuum cleaner and the
hand-mixer took place in the family’s home. Preintervention, intervention, and follow-up measures were collected in one of four rooms in his house: the sunroom,
playroom, dining room, and living room. Jeff’s mother
and a clinician from our center were present during all
sessions. Sessions for the blender also took place in the
family’s home and in the same rooms as the vacuum
and the hand-mixer. However, additional sessions were
implemented at Blenders, Baskin Robbins, and Starbucks stores for generalization.
Design and Procedure
The effects of systematic desensitization on auditory
hypersensitivity were assessed within the context of
three experimental designs (Barlow & Hersen, 1984). A
clinical replication was implemented using a replication
of the desensitization procedures for all three children.
A changing criterion design was used to systematically
advance each child through steps in a desensitization
hierarchy. Finally, a systematic replication across three
different stimuli (vacuum, blender, and hand-mixer) is
presented for Jeff in a multiple baseline.
Baseline
For Lori, data were recorded on her reaction to the
toilet flushing when school staff took her to the bathroom. For Jamie, data were recorded on his reaction to
the sight and sound of toys that made animal sounds;
specifically, a Mattel “See and Say” was used to assess
his reaction to these noises during all phases of the
intervention. For Jeff, data were recorded on his reaction to the mention, sight, and use of the vacuum
cleaner and hand-mixer under normal household conditions while his mother engaged in typical, everyday
interactions and activities with her son. Similarly, data
were recorded on his reaction to the blender when his
mother took him to Blenders.
Intervention
For all three children, intervention steps were developed by a team that included our staff and the individuals who interacted most frequently with the child
when the hypersensitivity was occurring. For Lori, this
was her teacher; for Jamie and Jeff, these were their
mothers. These individuals interacted with the child
during intervention while a clinician assisted with the
fading steps. The parents and teachers were asked not
to move forward in the hierarchy or to present the targeted stimulus to the child without the clinician present,
with the exception of Jeff. Jeff’s sessions were conducted weekly by the clinician, and Jeff’s mother was
encouraged to use the most recently completed step in
the hierarchy throughout the week if it was convenient
for the family and if Jeff appeared comfortable. The
clinician kept in close contact with Jeff’s mother during
the week by telephone and e-mail. For all children, the
criterion for completing a step in their respective hierarchies was two to four consecutive 3-minute intervals
scored as “comfortable.” Specific steps for each child
are described below and are presented in Tables 1, 2,
and 3 for Lori, Jeff, and Jamie, respectively. Further
details pertaining to the length of steps and the number
of steps completed per day or per week are described
for each child in the Results section.
For Lori, steps 1 through 4 were designed to increase
her comfort with the toilet area. Step 1 consisted of
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Using a Systematic Desensitization Paradigm
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Table 1
Systematic Desensitization Hierarchy for Lori
Step #
1
2
3
4
5
6
7
8
9
10
11
12
13
Hierarchy Description
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
Toilet
is
is
is
is
is
is
is
is
is
is
is
is
is
not flushed while Lori walks by
not flushed while Lori walks by
not flushed while Lori walks by
not flushed while Lori walks by
not flushed while Lori walks by
flushed repeatedly while Lori is
flushed repeatedly while Lori is
flushed repeatedly while Lori is
flushed repeatedly while Lori is
flushed repeatedly while Lori is
flushed repeatedly while Lori is
flushed repeatedly while Lori is
flushed repeatedly while Lori is
the bathroom door. The bathroom door is closed completely.
the bathroom door. The bathroom door is slightly cracked.
the bathroom door. The bathroom door is 1/4 way open.
the bathroom door. The bathroom door is 1/2 way open.
the bathroom door. The bathroom door is completely open.
approximately 75 feet from the bathroom door.
approximately 50 feet from the bathroom door.
approximately 25 feet from the bathroom door.
approximately 20 feet from the bathroom door.
approximately 10 feet from the bathroom door.
at the bathroom door.
inside the toilet stall. Door to toilet stall is open.
inside the toilet stall. Door to toilet stall is closed.
Table 2
Systematic Desensitization Hierarchy for Jamie
Step #
Hierarchy Description
1
Animal sounds are played repeatedly outside of the clinic room (approximately 20 feet from the door). The clinic
room door is closed completely.
Animal sounds are played repeatedly outside of the clinic room (approximately 10 feet from the door). The clinic
room door is closed completely.
Animal sounds are played repeatedly outside of the clinic room (approximately 5 feet from the door). The clinic
room door is closed completely.
Animal sounds are played repeatedly outside of the clinic room (approximately 4 feet from the door). The clinic
room door is closed completely.
Animal sounds are played repeatedly just outside of—but held away from—the clinic room door. The clinic room
door is closed completely.
Animal sounds are played repeatedly just outside of the clinic room and pressed against the clinic room door. The
clinic room door is closed completely.
Animal sounds are played repeatedly just outside of the clinic room. The clinic room door is slightly cracked.
Animal sounds are played repeatedly just outside of the clinic room. The clinic room door is 1/4 way open.
Animal sounds are played repeatedly just outside of the clinic room. The clinic room door is 1/2 way open.
Animal sounds are played repeatedly inside the clinic room by clinician.
Animal sounds are played inside the clinic room by clinician. Jamie spontaneously verbally requests that the
clinician play various animal noises.
Animal sounds are played repeatedly by Jamie’s mother and/or alternated between Jamie and his mother.
2
3
4
5
6
7
8
9
10
11
12
having Lori enter the hall when the bathroom door was
closed. Steps 2 through 4 were designed to gradually
open the door of the bathroom. The remainder of the
steps (steps 5 through 13) involved Lori gradually moving closer to the bathroom with the toilet flushing.
For Jamie, the animal sounds were played repeatedly
and became increasingly louder as they were gradually
moved closer to the playroom where Jamie and his
mother engaged in his favorite activities, such as toy
play or eating a snack. In steps 1 through 9, Jamie was
unable to see the toy playing animal sounds; in steps 10,
11, and 12, he could see and interact with the toy while
the animal sounds were played repeatedly. Jamie’s systematic desensitization program was completed in one
session, and follow-up data were subsequently collected
at home. In addition, the clinician kept in close contact
with Jamie’s mother by telephone and e-mail to discuss
Jamie’s progress and ability to maintain stable levels of
comfort with similar toys at home.
For Jeff, steps 1 and 2 placed a turned-off vacuum,
blender, or hand-mixer into his environment and targeted his comfort with seeing the stimulus. Steps 3
through 12 allowed Jeff to become comfortable with
the sound of an out-of-sight vacuum, blender, or handmixer, becoming increasingly louder as it was moved
closer to where he was playing. Finally, in steps 13 and
14, Jeff was able to both see and hear an operating
vacuum, blender, or hand-mixer. Jeff’s comfort with the
blender did not generalize to Blenders; therefore, intervention was also implemented in the community
where the smoothie shop was located. Table 4 presents
the five additional hierarchical steps necessary for that
setting. Step 15 simulated walking into Blenders in the
child’s home setting. In step 16, a blender was turned
off and on repeatedly to approximate the making of
juice and smoothies inside the store. Steps 17 and 18
were designed to present the sound of a blender in
stores other than Blenders (i.e., Baskin Robbins and
Starbucks), and in step 20 Jeff entered Blenders while
juice and smoothies were being made.
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Koegel et al.
Table 3
Systematic Desensitization Hierarchy for Jeff
Step #
Hierarchy Description
0
1
Vacuum/Blender/Hand-mixer is mentioned prior to being used.
Vacuum/Blender/Hand-mixer is turned off and placed out of sight in an adjacent room, the sunroom. Jeff is
gradually transitioned into the room with the stimulus.
Vacuum/Blender/Hand-mixer is turned off and placed in any room Jeff enters. If Jeff remains in any room for an
extended amount of time, the stimulus is moved to different locations within the same room.
Vacuum/Blender/Hand-mixer is turned on in the back master bedroom. Both the bedroom door and the hallway
door are closed.
Vacuum/Blender/Hand-mixer is turned on in the back bedroom. The bedroom door is open and the hallway door
remains closed.
Vacuum/Blender/Hand-mixer is turned on in the back bedroom. The bedroom door is closed and the hallway door
is completely open.
Vacuum/Blender/Hand-mixer is turned on in the back bedroom. The bedroom door is 1/4-way open and the
hallway door is completely open.
Vacuum/Blender/Hand-mixer is turned on in the back bedroom. The bedroom door is 1/2-way open and the
hallway door is completely open.
Vacuum/Blender/Hand-mixer is turned on in the back bedroom. Both the bedroom door and the hallway door are
completely open.
Vacuum/Blender/Hand-mixer is turned on in the bathroom. Both the bathroom door and the hallway door are
completely open.
Vacuum/Blender/Hand-mixer is turned on in Jeff’s bedroom. The bedroom door is 1/4-way open and the hallway
door is open.
Vacuum/Blender/Hand-mixer is turned on in Jeff’s bedroom. Both the bedroom door and the hallway door are
completely open.
Vacuum/Blender/Hand-mixer is turned on in the sunroom just outside of Jeff’s playroom, yet remains out of sight.
Vacuum/Blender/Hand-mixer is turned on in the sunroom just outside of Jeff’s playroom and is visible.
Vacuum/Blender/Hand-mixer is turned on in the same room as Jeff and is in sight.
2
3
4
5
6
7
8
9
10
11
12
13
14
Table 4
Systematic Desensitization Hierarchy: Additional Steps Implemented for the Blender for Jeff
Step #
15
16
17
18
19
20
Hierarchy Description
Blender is turned on while Jeff and his mother are outside. Jeff and his mother enter the house (where his
favorite toys are available) to simulate entering Blenders.
Blender is turned off and on repeatedly to simulate sound made at Blenders.
Jeff and his mother enter Baskin Robbins while blender is turned on.
Jeff and his mother enter Starbucks while blender is turned on at.
Jeff and his mother play with his favorite toys near the entrance of Blenders.
Jeff and his mother enter Blenders while blender is turned on.
Follow-Up
Follow-up probes were conducted after the completion of intervention for each child under conditions
identical to baseline. Follow-up probes for Lori were
taken when her teacher took the children to regularly
scheduled toileting sessions. Jamie and his mother
played together while follow-up probes were taken with
both stimuli used during the desensitization program (a
Mattel “See and Say” toy) and toys his mother brought
in from their home that made animal sounds, and to
which he had previously responded negatively. Additionally, follow-up data were collected in the family’s
home for generalization. Jeff’s mother was instructed to
engage Jeff in typical, everyday interactions and activities under normal household conditions and data were
recorded on Jeff’s reaction to the mention, sight, and
use of each auditory stimulus.
Dependent Measures
Dependent variables were (a) the number of hierarchical steps completed with the child’s anxiety level
judged as comfortable per week and (b) the mean level
of anxiety per session. Criterion for a step completed
was two to four consecutive 3-minute-intervals scored
as “comfortable.”
An interval recording system (in continuous 10second intervals) was used to rate the children as appearing comfortable, exhibiting mild or high anxiety, or
appearing as if the auditory stimulus was intolerable.
Comfortable was defined as the absence of any anxiety
relating to the stimulus and the child appeared to be
relaxed, engaged happily in typical play and interactions, and unaffected by the sight or sound of the stimulus. Mild anxiety was defined as engagement in behaviors such as delaying attention to a game or activity,
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Using a Systematic Desensitization Paradigm
short whining or whimpering, and brief periods of the
child covering his or her ears with his or her hands
when the stimulus was introduced. These behaviors
briefly delayed but did not interfere with the activity.
High anxiety was defined as the child exhibiting behaviors such as slowly moving away from the sight or sound
of the stimulus, whining, and covering his or her ears to
the extent that the child could not participate, play, or
interact appropriately. Intolerable was defined as the
child exhibiting behaviors that suggested that the sight
or sound of the stimulus was a painful experience: running away from a game or activity, crying or screaming,
pushing his or her hands forcefully over his or her ears,
sweating, shaking, and grinding the teeth.
Observer ratings for each 10-second interval were
given numeric values (comfortable, 0; mild anxiety, 1;
high anxiety, 2; and intolerable, 3). Averages of these
scores were calculated every 3 minutes (18 intervals) to
obtain a mean anxiety score and plotted as probes
along the ordinates in Figures 2, 3, and 4.
Reliability
Using the same interval recording system described
above, two undergraduate psychology students, one
who was blind to the experimental conditions, independently recorded data for at least 33% of all sessions.
Data were scored via videotapes presented in random
order. Interobserver agreement was calculated by dividing the number of agreements by the total number
of agreements plus disagreements and multiplying by
100. An agreement was defined as both observers rating the child identically (comfortable, mild anxiety,
high anxiety, intolerable), whereas a disagreement was
defined as any discrepancy between the observers’ recordings. Mean interobserver agreement results were
96.8% across all sessions, with a range of 83% to 100%.
Results
During the systematic desensitization intervention
program, observers reliably judged all children to become comfortable with increasing steps in exposures to
each stimulus. At the end of treatment, each child was
judged to be comfortable with the stimulus in sight and
operated or turned on. In contrast to baseline sessions,
observers never judged the stimulus, at sequential
steps, to be intolerable for any of the children once
intervention began.
Figure 1. Number of steps in the systematic desensitization hierarchy completed as comfortable per session and per week for each
child.
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Koegel et al.
Figure 1 presents the number of hierarchical steps
Lori, Jamie, and Jeff completed per week during baseline, treatment, and follow-up conditions for the toilet
flush, animal noises, and vacuum, respectively, as a
clinical replication. Criterion for a step completed was
two to four consecutive 3-minute intervals scored as
comfortable.
In the top graph, baseline data indicate that Lori
failed to reach criterion levels of comfort at step 11
(toilet is flushed while Lori is at the bathroom door),
and sessions were terminated due to behaviors indicating that the toilet flushing was intolerable for her. In
contrast, steps completed during intervention reached a
stable level of comfort in each session. Completed steps
per day ranged from five to eight steps: steps 1 through
5 were completed during day 3 and steps 6 through 13
were completed during day 4. The data show a continuous increase in steps completed. Following intervention, Lori was able to be in the bathroom stall while the
toilet was flushed repeatedly. Furthermore, Lori’s comfort with the toilet flushing was maintained during follow-up probes taken 1, 8, and 15 days after completing
treatment.
In the lower-left graph, baseline data show that Jamie failed to reach criterion levels of comfort at step 12
(animal noise toy is played repeatedly), and sessions
were terminated due to behaviors indicating that the
animal noise toy was an intolerable stimulus for him.
Steps implemented during treatment, however, reached
a stable level of comfort in each session. All 12 steps
were completed during week 1. Jamie’s comfort with
the animal noises was maintained during follow-up
probes taken 1, 2, and 6 weeks after intervention was
completed.
In the bottom-right graph, baseline data indicate that
Jeff failed to reach criterion levels of comfort at step 0
(vacuum is mentioned prior to being used) and step 14
(vacuum is turned on and in sight), and sessions were
terminated due to behaviors indicating that the vacuum
was intolerable for him. In contrast, steps completed
during treatment reached a stable level of comfort in
each session. Completed steps per week ranged from
one to seven: step 1 was completed during week 6, step
2 during week 7, steps 2 through 8 during week 8, steps
9 through 13 during week 9, and step 14 during weeks
10 and 11. The data show a continuous increase in steps
completed. Following intervention, Jeff was able to
play comfortably with the vacuum nearby, turned on,
and in sight. Furthermore, Jeff’s comfort with the
vacuum was maintained during a follow-up probe taken
3 weeks after completing intervention. Figure 2
presents the number of hierarchical steps Jeff com-
Figure 2. Number of steps in the systematic desensitization hierarchy completed as comfortable per session and per week for the
vacuum, blender, and hand-mixer for Child 3 (Jeff) presented in a multiple baseline across stimuli design.
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Using a Systematic Desensitization Paradigm
pleted per week during baseline, intervention, and follow-up conditions across auditory stimuli in a multiple
baseline. In the bottom graph, baseline data show that
Jeff failed to reach criterion levels of comfort at step 20
(Jeff goes to Blenders while juice/smoothies are being
made), and sessions were terminated due to behaviors
indicating that the blender was an intolerable stimulus
for him. Additionally, a single baseline point indicates
that Jeff failed to reach criterion levels of comfort at
step 14 for the hand-mixer (hand-mixer is turned on
and in sight), and the session was terminated due to
behaviors indicating that the hand-mixer was yet another intolerable stimulus. Data collected during intervention showed that Jeff reached a stable level of comfort at each step in the desensitization hierarchy. Completed steps for the blender ranged from one to eight
steps per week: steps 1 and 2 were completed during
week 18, steps 3 through 10 during week 19, steps 10
through 14 during week 20, step 14 during week 23,
steps 15 through 17 during week 24, and step 18 during
week 25. Generalization probes during week 23 demonstrated that Jeff’s comfort with the blender at home
did not generalize to Blenders, so the session was terminated. Thus, additional steps (steps 15 through 19)
were created and implemented. These additional steps
led to generalization at Blenders (steps 19 and 20) during follow-up probes taken 4 weeks after completing
intervention. The bottom graph of Figure 2 also shows
generalization probes taken to evaluate Jeff’s reaction
to the hand-mixer during week 32. Without intervention for the hand-mixer, Jeff reached criterion levels of
comfort at step 14 (hand-mixer is turned on in the same
room and in Jeff’s sight), thereby demonstrating generalization. Additional probes were taken during week
33 and 34, in which Jeff again reached criterion levels of
comfort with the hand-mixer turned on and in sight.
Figure 3 presents Lori and Jamie’s mean level of
anxiety observed during the increasing hierarchical step
for the toilet flushing and animal noises, respectively.
In the top graph, baseline probes indicate that toilet
flushing caused observers to judge that the toilet was an
intolerable stimulus for Lori. Sessions on both days
were terminated because of her severe reaction to the
toilet flushing. During intervention, anxiety levels decreased from mild anxiety to comfortable and remained
relatively stable in the comfortable range following
completion of steps 1 and 2. The number of intervals to
reach criterion for a step completed as comfortable
ranged from four to nine. During the first day of intervention, step 1 was used and Lori’s anxiety was judged
to be in the comfortable range for four 3-minute intervals, meeting the criterion to advance to the next step.
In step 2, however, Lori’s anxiety was initially judged as
mild for one interval before reducing to comfortable for
the next seven intervals, thereby reaching criterion.
Lori was able to move from steps 3 through 7 on the
same day, and her anxiety was reliably observed as
129
comfortable. On day 2 of intervention, Lori’s anxiety
was judged to be comfortable in steps 8 through 10. In
step 11, her anxiety was initially judged to be mild for
one interval before again reducing to comfortable for
the next seven intervals. Observers continued to judge
Lori as comfortable during steps 12 and 13, thereby
completing the hierarchy. Step 13 was repeated at follow-up during days 5, 12, and 19, and Lori again was
observed to be comfortable, remaining stable for four
consecutive intervals on each day.
In the bottom graph, baseline probes indicate that
the Mattel “See and Say” animal noises toy caused observers to judge that the toy was an intolerable stimulus
for Jamie. Sessions were terminated because of his severe reaction to the noise. During intervention, anxiety
levels were judged in the comfortable range and remained relatively stable. The number of intervals to
reach criterion for a step completed as comfortable
ranged from two to nine. During week 1, step 1 was
used and Jamie’s anxiety was judged to be in the comfortable range for two intervals, meeting the criterion
to advance to the next step. In step 2, Jamie’s anxiety
was initially judged as mild for one interval before reducing to comfortable for the next eight intervals,
thereby reaching criterion. Jamie was then able to
move from steps 3 through 12 during the rest of week 1,
and his anxiety was reliably observed as comfortable.
Step 12 was repeated at follow-up during weeks 2, 4,
and 7, and Jamie again was observed to be comfortable,
remaining stable for four consecutive intervals on each
day.
Figure 4 presents Jeff’s mean level of anxiety—
ranging from comfortable to intolerable—observed
during the increasing hierarchical steps for the vacuum,
blender, and hand-mixer. In the upper-left tier of the
top graph, baseline probes indicate that both mentioning the vacuum and turning it on caused observers to
judge that the vacuum was an intolerable stimulus for
Jeff. During the first baseline probe, mention of the
vacuum produced behaviors suggesting that it was an
intolerable stimulus, and the session was terminated.
The second baseline probe shows Jeff’s intolerance
with the vacuum when it was turned on; thus, the session was again terminated. Finally, the vacuum was
mentioned once more during the third baseline probe,
and the session was terminated following stable levels
of behavior again suggesting to observers that it was an
intolerable stimulus. During intervention, anxiety levels
decreased from high anxiety to mild anxiety to comfortable and remained relatively stable in the comfortable range following completion of step 2. The number
of intervals to reach criterion for a step completed as
comfortable ranged from 2 to 34. During week 6, step 1
was used and Jeff’s anxiety initially was judged to be
high for six consecutive intervals. His anxiety reduced
to mild for the next four intervals before reducing again
to comfortable and reaching criterion for the final four
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130
Koegel et al.
Figure 3. Mean level of anxiety per 3-minute interval in each hierarchical step for toilet flush for Child 1 (Lori) and animal noises
for Child 2 (Jamie).
intervals. Jeff was able to move up to step 2 during
week 7, and his anxiety was reliably observed as low,
with the exception of an increase to high anxiety during
two intervals. Criterion was not met for step 2 during
week 7; thus, this step was reintroduced during week 8
until criterion was met after four consecutive intervals
were judged as comfortable. Jeff’s behavior was observed to be comfortable during both intervals of step 3
and in the low anxiety to comfortable range during step
4. Levels of comfort remained stable through the rest of
the intervals in steps 5 through 8. Observers continued
to judge Jeff as comfortable during steps 9 through 12
the following week. In step 13, his anxiety was initially
judged to move in and out of the comfortable range
before remaining comfortable for the final five intervals. Jeff completed step 14 (vacuum is turned on, in
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Using a Systematic Desensitization Paradigm
131
Figure 4. Mean level of anxiety per 3-minute interval in each hierarchical step for the vacuum, blender, and hand-mixer for Child
3 (Jeff).
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Koegel et al.
sight, and in the same room) during weeks 10 and 11.
Step 14 was repeated at follow-up, and Jeff again was
observed to be comfortable and remained stable for
five consecutive intervals. In the upper-left tier of the
middle graph, baseline probes show that going to
Blenders (step 20) elicited behaviors suggesting that the
blender was an intolerable stimulus, and the session
was terminated. Following intervention of the vacuum
during week 11, a second probe taken at Blenders (step
20) was taken for generalization and indicated that going to Blenders continued to produce behaviors that
suggested the blender was causing high anxiety, and the
session was again terminated. During intervention,
anxiety levels decreased from intolerable to high, then
to mild, before remaining relatively stable in the comfortable range. The number of intervals to reach criterion for a step completed as comfortable ranged from 2
to 11. Observers judged Jeff to remain in the comfortable range for steps 1 through 9. During week 19, Jeff
was observed to be comfortable for three intervals of
step 10 before he was judged to have mild anxiety for
one interval. Although Jeff quickly returned to the
comfortable range for the following two intervals, step
10 was repeated during week 20. His anxiety initially
was judged to be mild for one interval before reducing
to comfortable and reaching criterion for the final four
intervals of step 10. Observers judged Jeff to be comfortable throughout step 11 and then to demonstrate
low levels of anxiety during the first interval of step 12
before returning to comfortable for six consecutive intervals. Thus, Jeff was systematically advanced to steps
13 and 14. Step 14 was repeated during week 23, and his
anxiety was initially judged to move in and out of the
comfortable range before remaining comfortable for
the final six intervals. A generalization probe was then
taken at Blenders in which judges observed Jeff’s behavior to be in the high anxiety range. Thus, steps 15
through 19 were implemented to more closely simulate
Blenders. During step 15, Jeff’s anxiety was initially
judged to be low before remaining comfortable for the
final three intervals. Levels of comfort remained stable
for steps 17 through 19. The final test of whether general-case procedures would be effective was used at
follow-up, where step 20 (Blenders) was repeated and
Jeff was observed to be comfortable and remained
stable for five consecutive intervals. The bottom graph
presents the results of a further test of whether generalcase procedures would produce a generalized level of
anxiety reduction to this type of auditory stimuli. The
upper-left tier of the graph shows a baseline probe indicating that turning on the mixer (step 14) caused observers to judge that the mixer was an intolerable
stimulus for Jeff, and the session was terminated. Following intervention for the blender, a second probe of
the mixer (step 14) was taken for generalization during
week 32. Initially, observers judged Jeff’s behavior to
be in the mild anxiety range before remaining stable in
the comfortable range for three consecutive intervals.
Step 14 was used again in week 33 and week 34, in
which observers reliably judged Jeff to remain comfortable for four intervals. Overall, the data show that anxiety levels remained low throughout intervention for the
vacuum and the blender and at follow-up for the handmixer. Thus, observers judged Jeff as comfortable
throughout much of the intervention and able to maintain comfort in the presence of an operating vacuum,
blender, and hand-mixer.
Discussion
These results suggest that the intense reactions to
auditory stimuli many children with autism exhibit may
be related to a phobia rather than pain associated with
a stimulus. Specifically, the extreme reactions the children displayed at baseline (running away from various
auditory stimuli, loud and severe screaming, forcefully
covering ears, sweating, shaking, and grinding teeth)
might easily have suggested that the children were in
pain. However, the data indicate that hypersensitivity
to the sound of the stimuli may have been a conditioned
response that could be treated with a counterconditioning behavioral intervention (systematic desensitization)
typically used to treat phobias in children (Center,
1989).
As mentioned earlier, it has been reported that many
children with autism seem to have hypersensitive hearing (Grandin & Scariano, 1986; Hayes & Gordon, 1977;
Ney, 1979; Rimland, 1964; Rimland & Edelson, 1995).
The current study suggests that if hypersensitivity is
indeed causing children with autism to display aversive
reactions to auditory stimuli, then hypersensitivity is
more complex than we originally thought, yet relatively
easy to overcome. Clinically, whether such reactions
are due to hypersensitive hearing or an unrelated phobia, this study suggests that children may respond favorably to the same type of intervention (systematic
desensitization). Theoretically, though, if the children’s
intolerant reaction to aversive auditory stimuli were entirely due to hypersensitivity, their responses would be
relatively unchangeable with desensitization, or at least
not likely to move into the comfortable level. The data,
however, show that the responses of all three children
could be quickly and easily modified to the point where
they appeared completely comfortable. Following intervention and at follow-up, all children were reliably
rated to be comfortable in the presence of operating
auditory stimuli that at baseline appeared to be intolerable. Thus, the children not only tolerated the sight
and sound of these stimuli but also displayed behaviors
that suggested they were comfortable (i.e., playing,
smiling, laughing, and interacting with mother or therapist appropriately). Again, these results indicate that
each child’s initial reaction to aversive auditory stimuli
may have been phobic rather than painful. Thus, the
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Using a Systematic Desensitization Paradigm
data extend reports of phobias in children with autism
(Howlin et al., 1973; Jackson & King, 1982; Love, Matson, & West, 1990; Luiselli, 1978) to include the extreme reactions they display in the presence of auditory
stimuli.
Further indicating that the intense reactions to auditory stimuli were related to a phobia was Jeff’s ability to
drink a Blenders smoothie at follow-up. In describing
procedures of desensitization, Wolpe (1973) suggested
that there were incompatible responses to fear and
anxiety. In addition to relaxation and sexual arousal,
digestion has been reported to be incompatible with
fear. In all baseline sessions and in the generalization
probe taken during week 23, Jeff would not drink his
smoothie, even if offered to him outside of the store or
in the car on the ride home. At follow-up, however, Jeff
accepted the drink from his mother and appeared comfortable while consuming the entire smoothie. This observation supports the finding that Jeff’s intolerant reaction to auditory stimuli—which initially appeared to
be related to pain associated with the stimulus—may
have been a conditioned response.
The exact nature of the original conditioning, as with
most phobias, is difficult to determine. In future research, it might be interesting to attempt to understand
whether, or how, such conditioning occurred. One possible explanation for such conditioning may be stimulus
overselectivity, a deficit in children with autism that has
been validated empirically (Koegel & Wilhelm, 1973;
Lovaas & Schreibman, 1971; Lovaas, Schreibman, Koegel, & Rehm, 1971; Reynolds, Newsom, & Lovaas,
1974). In other words, children with autism often respond to only one component of a stimulus, which
seems to prevent them from acquiring and generalizing
behaviors (Lovaas, Schreibman, Koegel, & Rehm,
1971). It is possible, then, that overselectivity may have
caused the children to attend only to auditory stimuli
and prevented them from responding to other and
more relevant components of their environment. While
young, typically developing children may become
frightened by loud noises (e.g., vacuums, blenders, and
hand-mixers), auditory overselectivity may have caused
the children in this study to fail to associate the auditory
stimuli with positive reinforcers. Thus, the children’s
reactions to auditory stimuli may have been a conditioned phobic response due to their inability to respond
to other stimuli in their environment.
This explanation is further supported by the intervention for stimulus overselectivity: teaching responsivity to multiple cues (Koegel & Schreibman, 1977;
Schreibman & Koegel, 1982). Although competing reinforcers (i.e., small treats and snacks, toys and activities, and social interaction games) were used as anxiety
inhibitors, they may have simultaneously taught the
children to respond to multiple stimuli while auditory
stimuli were gradually and systematically introduced
into their environments. As each child learned to re-
spond to both the competing reinforcers and auditory
stimuli, their responses to auditory stimuli may then
have been counterconditioned, allowing them to seem
comfortable in the presence of such stimuli. This hypothesis also is consistent with other similar theories of
perceptual dysfunction in children with autism (Courchesne, Yeung-Courchesne, & Pierce, 1999; Cox &
Schopler, 1993; Ritvo, 1983; Schopler, 1978; Schopler &
Mesibov, 1995).
In addition to having theoretical importance, the
children’s ability to become comfortable with stimuli
that were judged to be intolerable is socially significant.
For example, as noted earlier, the children’s reactions
to the common stimuli negatively affected their (and
often their family’s) ability to participate in everyday
settings. Following intervention, they were able to participate in all settings and the families did not need to
avoid specific settings or alter their lifestyles because of
possible negative effects they may have on their child.
Jeff and Jamie’s mothers reported that they both felt
personal anxiety about the stimuli causing apparent
pain to the child, and that the absence of any intense
reaction related to the auditory stimulus following intervention had greatly improved the family’s quality of
life.
Overall, the current study suggests that one cause for
extreme responses to auditory stimuli may be due to
the development of phobias. Thus, next steps in this
type of research might be to look at whether there are
multiple causes to children with autism’s extreme reactions to auditory stimuli and to examine the generality
of changes. In any case, the results of the current study
suggest that a hierarchical desensitization program may
be helpful in eliminating apparent sound sensitivities in
children with autism.
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Received: March 14, 2004
Final acceptance: June 30, 2004
Editor in charge: George H. S. Singer
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